Vancomycin-resistant Entercocci as a Possible Bio-Terrorist Weapon and Health Care Defense Tactics - Term Paper Example

Vancomycin-resistant Entercocci as a Possible Bio-Terrorist Weapon and Health Care Defense Tactics Vancomycin Resistant Entercocci (VRE) is a bacteria found commonly in human intestinal tracts and vaginal canals. Over the last decade Entercocci has become increasingly resistant to antibiotics, including Vancomycin. The feasibility of using VRE as a bio-terrorist weapon is a possibility as the bacteria is difficult to treat, is acquired and transmitted easily, and has been shown to transfer genetic resistance to other gram-positive organisms in the laboratory environment. The effects of VRE used as a bio-terrorist weapon can be reduced by improved infection control, nursing research, strict adherence to universal precautions and improved methods of detection. Entercocci are gram-positive bacteria and all Entercocci have an intrinsic resistance to antibiotics. This resistance has increased since 1988 when it was first seen as a public health risk in Europe. Vancomycin Resistance Entercocci (VRE) was first identified in the United States in 1993. “From 1993 the proportion of entercoccal isolates resistant to vanomycin reported to the National Nosocomical Infections Surveillance System increased 20-fold.” (McDonald n.d. para 1) Enterococci is found the gastrointestinal and female genital tracts and identified in lab reports as Enterococci faecium, Entercocci faecallis or Entercocci species. This bacteria is found along catheter sites and in urine without causing infection. (Community Health Administration guidelines 1996, Background) The infection usually occurs after an introduction of the bacteria into a preciously sterile environment. A procedure such as in-dwelling catheters, cardiothoracic surgery, transplants and extended stays in ICU wards increases the risk of acquiring VRE. One method of transfer was discovered in the use of a suction device that removes oral and nasal secretions common in the ICU and Yankauer Catheters. (Kayyali 2006 para 1) VRE also spreads easily by computer keyboards with or without covers. Since most health care documentation is done electronically, this is a serious concern in all areas of the hospital, but in particular, critical care units. Long Term Care facility (LTC) patients are also at risk. VRE and Methacillin Resistant Staphyloccos Aureus (MRSA) have been shown to survive on keyboards for an hour and on covers for five minutes. Bare hands transferred the bacteria at a considerably higher percentage than gloved hands. (Computer Bugs, 2005 pg 1) As a bio-terrorist weapon VRE is attractive due to easy access and the ease of transmission, especially in hospital settings and LTC facilities where patients come into contact with outsider visitors. Hospital and LTC facility patients carry a higher risk of contracting VRE infections due to conditions that inhibit their immune systems. The disturbing fact that VRE has been shown in one laboratory case to spread genetic mutation to MRSA, makes VRE an excellent weapon choice for bio-terrorists. If MRSA were to become resistant to Vancomycin it would be untreatable. (CHA 1996 pg 2) In the United States acquisition and transference of VRE outside hospital settings is not supported by data. Colonization nearly always precedes the majority of infections in European studies, which indicates that colonization occurs in the community. European reports also show that,”VRE exists in animal feces and in human foods originating in animals.” (McDonald, 1997 para 3). This implies a relationship between the community and nosocomical infections. The most common form of Entercocci is E. faecalis, responsible for 80% of colonizational human infections. As a possible weapon Entercocci are ideal in that they are an extremely resilient bacteria able to withstand wide temperature ranges, hypertonic, hypotonic, acidic and alkaline environment. Entercocci grow under reduced or oxygenated conditions and can tolerate solutions of bile salts that kill other organisms. (Huycke, 1998 pg 240) At this time E. faecalis usually does not exhibit resistance to ampicillin or Vancomcin, however, another Entercocci group does. Entercocci faecium has shown a starling rate of 52% increase in resistance to Vancomycin. While this group comprises only around 20% of infection origins, it demands consideration that there is no reason that resistance to ampicillin and Vancomycin would not also benefit E. fecalis and in fact may effect that group more in the future. As frightening as it may seem for a bio-terrorist organization to use VRE as a weapon against humanity, the best defenses are already in place-infection control and sanitation regulations can limit the effects of a possible future attack. Included in Infection Control are universal precautions and the use of antibiotics. With the current widespread nosocomical antibiotic resistant infections it has become necessary to focus attention on the misuse, over use of antibiotics. The most common infections associated with inappropriate antibiotic use are VRE and clostridium difficile. (Lautenbach Chapt 14 Background para 2) Colonization rarely begins in the intestinal tract, but probably originates in the community with contaminated water or animal feces. The best defense against VRE as a natural occurrence or as an enemy vector is to prevent colonization in the outdoor environment as little is understood concerning patient to patient transfer in the hospital setting. Patients exhibiting VRE infections in hospital settings have usually been on broad spectrum antibiotic therapy, which does not have an effect on Entercoccal bacteria. In addition, antibiotics reduce the natural ability of the anaerobic flora in the colon to fight bacteria. Such therapy should include all antibiotics to avoid opening the door for VRE infection to flourish. (Huycke 1998 pg 242 Infection Control) Lautenbach suggests a reform in antibiotic prescription protocol to correct inappropriate use or incorrect duration of antibiotic therapy. “The overuse of vancomycin has been implicated in promoting an increase in VRE. Education of antibiotic prescribers is also important.” (CHA 1996 pg3) A bio-terrorist attack has greater consequences than the illness and deaths directly caused by the pathogen. Infections acquired in hospitals increase costs and decrease wages earned by the patient, which effects the economy. Nosocomical infections cost around 4.5 billion dollars and more than 80,000 deaths in 1995. Each nosocomical infection adds an average of $2100 to a hospital bill. (NINR Advisory Team 1999) “Antimicrobial resistant infections have created a ‘silent epidemic’ In communities and hospital across the country. “ Dr. Blaser said, crippling and killing a growing number of otherwise-healthy people and driving up health care costs. To make matters worse, the pharmaceutical industry has lost interest in developing new antibiotics to fight these infections because they are not as profitable as drugs for chronic conditions such as heart disease. IDSA outlined this problem and proposed solutions in its July 2004 report, Bad Bugs, No Drugs: As Antibiotic Discovery Stagnates: A Public Health Issue. (Infectious Disease 2006 News) While it may not be possible to prevent a bio-terrorist attack or convince drug companies to produce new antibiotics, it is possible to use what is available most effectively by early diagnosis of infection. Walter Reed Army hospital researchers are working on a method of diagnosis within hours of being exposed to a bio-terrorist agent. Unlike other methods of detecting infection these researchers are studying gene pattern response after exposure to biological threat agents (BTA). Rapid diagnosis would allow antibiotics already available to be more effective. Within two hours of exposure bacterial toxins manipulate gene expression. While the technology is still in development for this type of detection, researcher at Walter Reed expect to see in the near future a hand held device for use on site during BTA attacks. (ASM Biodefense Research Meeting 2006.) Medline studies examined by Lautenbach the efforts to change the use of antibiotics reduced infection in all but three of those studies. In the three that produced negative results Dr. Lautenbach suggested that the results in those cases could be attributed to patient to patient transfer via health care workers. Controlling VRE infections is within current abilities, but cost is a consideration for hospitals to study changing protocol for antibiotic prescription therapy. The benefits would outweigh the costs both in peace time and during bio-terrorist attack. A main obstacle to improving barrier precautions is the attitude of healthcare workers, including physicians, who were 50% less likely to enter the rooms of contact isolation patients. The more complicated the interventions the less likely workers will adhere to it. (Lautenbach Chapter 13.n.d. pg 4 para 3 ) The time necessary to prepare to enter rooms of isolated patients is a major contributor to lack of infection control compliance. Over worked healthcare professionals are reluctant to don gloves, masks and gowns. Strict adherence to infection control regulations could reduce the emergence of VRE and other nosocomical infections. Adding to the bio-terrorist risk is the fact that infectious diseases thought to be eradicated in the United States were the third leading cause of death in 1992. The combination of an aging population, impaired immune systems and uncontrolled immigration is compounding the problem of resistant pathogens. (NINR 1999) The gaps in recent medical research could be filled in by nursing research which focuses on applied behaviors outside of the acute environment, such as schools, LTC facilities, prisons and recreational facilities. Effectively controlling all infections, including resistant pathogens will necessarily include community education and lifestyles changes. Part of the mission statement of the National Institute of Nursing Research (NINR) is “to prevent or delay the onset of disease and disability.” (NINR 1999) In the June 1999 meeting of the NINR discussions of modern preventive health care measures focused on nursing homes, ambulatory care and private homes. Chronically ill patients are no longer segregated in institutions like the tuberculosis patients of the past, but live at home and participate in out patient programs. LTC residents also have frequent contact with the public. Another population no longer segregated are the developmentally disabled who are medically fragile. Many residents of state hospitals who first entered communities in the early 1990s were exposed to pathogens previously known to their population. The United States population is changing and that of Western Europe with immigration rapidly introducing different ethnic groups and cultures that will affect public health care. The feasibility of VRE as a bio-terrorist weapon can be circumvented by medical and nursing research working together. Since a major contributor to lack of infection control adherence is overworked employees, attention needs to also focus on the nursing shortage and how to best correct the situation. “Increasing drug resistance cuts across and compounds all these issues, as therapies that once were standard for infections become largely ineffective. The striking result is that trends in U.S. mortality data over the last century show no change in the slope following the introduction of antibiotics” (NINR workshop report 1999) In Europe VRE has been found outside the health care setting in sewage treatment plants in England and small towns in Germany. (McDonald 1997. pg 2 para 1) VRE was also found in uncooked chicken in retail stores and in manure samples from pig and poultry farms. A relationship has been discovered between the antibiotic used in animals, avoparcin and VRE in the Netherlands, Denmark and Norway. VRE colonization has been found in humans not associated with health care in Europe indicating a causal relationship between VRE in the community and VRE in health care settings. With the ease of air travel and increasing immigration, the United States needs to keep a watchful eye on VRE colonization in Europe and the relationship to antibiotics in food animals. The use of antibiotics in food production in the United States is prevalent and while there appears to be little incidence of VRE colonization outside the hospital setting now, this situation could easily and suddenly change. The antibiotic associated with VRE colonization in Europe is not licensed in the United States or Canada due to a carcinogenic potential. (McDonald n.d. pg 3,4 ) Opponents of the ban against avoparcin, which is used in subtherapeutic doses in animal feed for increased growth, point out that there is a low occurrence in Europe of human VRE colonization compared to the United States. One possible reason for this is the increased use of vancomycin, a glycopeptide, in the U.S. Dr. Huycke of the Infectious Diseases Section at the Oklahoma University Health Sciences Center, states that controlling the emergence of resistant bacteria depends on responsible use of antibiotics in hospitals and research to develop new drugs. This combined with public education regarding the importance of hand washing and correct techniques and persistent infection control compliance from health care workers can reduce the threat of infectious disease from sources or bio-terrorist origin. At the NINR workshop in 1999, three types of interventions were identified; 1. behavioral/educational (e.g., school-based educational programs to improve handwashing practices) 2. engineering and technological (e.g., strategic location of automates sinks) 3. organizational/contextual (e.g., nursing home policy to promote vancomycin-resistant entercocci monitoring and surveillance) At the first Interpol Global Conference on Bioterrorism in March 2005 it was suggested that enhancing cooperation between public health officials, customs and law enforcement and creating an incident response guide would aid in handling BTA attacks. Bioterrorism is a threat due to the public being unprepared and uneducated regarding Bioterrorism. (Interpol Newsletter 2006) The field of nursing is on the front line in the prevention and containment of infectious diseases. The NINR Workshop panel targeted four areas where nursing research could contribute to infection prevention and containment. 1. Characterizing risks 2. Understanding relevant beliefs and practices 3. Testing efficacious interventions in new settings 4. Enhancing the effectiveness of interventions with demonstrated efficacy. With the immigrant populations increasing the NINR presented the idea of studying the health care beliefs and traditional folk medicine cultures regarding detection and treatment of infectious diseases. Understanding these beliefs could possibly motivate immigrant populations to accept the use of antibiotics and adopt preventive health care measures such as handwashing, vaccines and general hygiene practices. (NINR Workshop Report pg 4). If Infection Control can be improved and regulations strictly enforced the impact of a bio-terrorist attack using VRE could be drastically reduced. While microbiologists and physicians develop vaccines and treatment protocols, it is ultimately up to direct care professionals to ensure that infectious diseases return to the low level threat of thirty or forty years ago. Bio-terrorists rely on weak links and apathy to cause the maximum amount of damage. International and local cooperation between the public, health care officials and law enforcement could significantly reduce the threat and impact of any bioterrorist attack. Increased infection control education and adherence to regulations can not only improve patient care and reduce costs, but also send a message to terrorists that using bacterial toxins in an ineffective weapon. Works Cited Community Health Administration. (1996) VRE Guidelines. Retrieved on April 10, 2006 from the Community Health Administration. http://www.edcp.org/guidelines/vre96.html American Society of Microbiology. (Feb 21 2006). Gene Patterns in White Blood Cells Quickly Diagnose If Someone Has Been Exposed to a Bioterrorism Agent. Retrieved April 12, 2006, from http://www.medicalnewstoday.com/medicalnews.php? Newsid=37969 Huycke, Mark M., Sahm, Daniel F. and Gilmore, Michael S. (April-June 1998). Multiple-Drug Resistant Entercocci: The Nature of the Problem and an Agenda for the Future [Electronic Version]. Emerging Infectious Diseases, Vol. 4 (2), 239-49 Kayyali, Andrea MSN, RN. (January 2006). Yankauer Catheters Can Harbor Many Pathogens.[Electronic Version]. AJN, American Journal of Nursing. Vol. 106, 72A-73A Interpol. (n.d.) Bioterrorism. Retrieved on April 12, 2006, from http://www.interpol.int/Public/BioTerrorism/ Lautenbach, Ebbing, M.D., M.P.H., MSCE. n.d.. Impact of Barrier Precautions in Reducing the Transmission of Serious Nosocomical Infections. Chapter 13. Retrieved April 10, 2006, from http://www.ahrq.gov/clinic/ptsafety/chap13.htm Lautenbach, Ebbing, M.D., M.P.H., MSCE. n.d.. Impact of Changes in Antibiotic Use Practices on Nosocomial Infections and Antimicrobial Resistance-Clostridium Difficile and Vancomycin-resistant Enterococci (VRE). Chapter 14. Retrieved April 10, 2006, from http://www.ahrq.gov/clinic/ptsafety/chap14.htm McDonald, L. Clifford, Kuehnert, Matthew J., Tenover, Fred C., and Jarvis, William R. (September 1997). Vancomycin-Resistant Enterococci Outside the Health-Care Settings: Prevalence, Sources, and Public Health Implications. [Electronic Version]. Emerging Infectious Diseases, 3 (3) National Institute of Nursing Research (NINR(. (1999). Interdisciplinary Group Advises NINR On Research Opportunities and Challenges in Emerging Infections. Workshop. Retrieved April 10, 2006, from http://ninr.nih.gov/ninr/news-info/workshop699.htm National Institute of Nursing Research (NINR(. (1999). Identifying Research Opportunities at NINR: A Case in Point. Workshop Report. Retrieved April 10, 2006, from http://www.nih.gov/ninr/Conf.htm News Update, (July 2005). Clinical Rounds: These Computer Bugs Transmit Disease. [Electronic Version] Nursing 2005. 35 (7) pp 35-35 Retrieved on April 10, 2006, from http://www.nursingcenter.com/library/journalarticleprint.asp?Article-ID=591014 Pages used in research to follow; http://ninr.nih.gov/ninr/news-info/workshop699.htm INTERDISCIPLINARY GROUP ADVISES NINR ON RESEARCH OPPORTUNITIES AND CHALLENGES IN EMERGING INFECTIONS Responding to the growing threat of emerging infectious diseases (EIDs) and the gaps in current research, the National Institute of Nursing Research (NINR) invited an interdisciplinary team to help shape the nursing research agenda and determine how nursing might contribute to control of EIDs.  Emerging Infections: A Once and Future Threat Infectious disease, thought just two decades ago to be nearly eradicated in this country, was the third leading cause of death in the United States in 1992, dropping to eighth in 1996. 11  Between 1980 and that year, overall U.S. mortality from infectious disease rose 58 percent, of which 22 percent was due to agents other than HIV.1   Although the major costs of these infections must be measured in human suffering and death, the direct and indirect financial costs are significant. For example, nosocomial infections cost an estimated $4.5 billion and contributed to more than 88,000 deaths in 1995.2   Each nosocomial infection adds an average of $2,100 to a hospital bill. Community-acquired infections are also costly: for example, the measles resurgence in 1989-1991 cost more than $100 million in direct medical care.3 Experts predict that in coming years, infectious diseases caused by both new and reemerging pathogens will grow in significance as a public health issue in the U.S. One reason for this upsurge is the increased exposure of humans to infectious agents through changes in life style, international travel, and globalization of the food industry. Increased use of antimicrobials has contributed to the emergence of multidrug-resistant microorganisms. The use of pesticides and damage to the natural environment (for example, suburban sprawl and shrinking deer habitats, leading to the emergence of Lyme disease) are other contributors.4 This countrys vulnerability to infection is heightened by the growth in populations at particular riske.g., the elderly, people with impaired immune systems or other chronic illnesses, and refugees and other immigrants. To these challenges is added the impact of managed care, which is shortening hospital stays and shifting the focus from acute care to a wide range of health care settings and the community.  Increasing drug resistance cuts across and compounds these issues. While the public may retain its faith in an antibiotic shield against infection, in reality, "for every class of [antimicrobial] drugs developed by the pharmaceutical industry, theres a mechanism of resistance" before much time elapses. 5   Therapies once standard for infections have become largely ineffective. The striking result is that trends in U.S. mortality data over the last century show no change in the slope following the introduction of antibiotics. (See Figure 1. 6 )  Current Research Research on infectious disease encompasses ecologic and environmental factors, microbial changes and adaptations, human susceptibility, and control and prevention strategies. The federal agencies responsible for this research increasingly are stressing partnerships, not only with each other but also with the private sector and international organizations and agencies. Mathematical modeling is a promising new tool being applied to both acute care and other settings, to examine factors such as risk and cost-effectiveness in all types of health care settings.  The Centers for Disease Control and Prevention (CDC) in 1994 launched a nationwide effort to combat emerging and reemerging infectious diseases, involving surveillance, research, prevention, and infrastructure development.7   New funding for building preparedness against a bioterrorist episode is enabling CDC to develop its information and surveillance systems and its capability for two-way communication with local and state partners. Those same systems can be used for dealing with emerging infections.  The Healthcare Infection Control Practices Advisory Committee (HICPAC) within the Hospital Infections Program of The National Center for Infectious Diseases (NCID) develops prevention guidelines and is exploring ways to assess their impact. Currently, there are few data on which to base guidelines for infection control outside the acute care setting. One goal is to develop an evidence base for future interventions, both within hospitals and in other settings in which health care is delivered.  Within the National Institutes of Health (NIH), eleven of the twenty two funding components participated in 1996 in an ad hoc working group on Emerging Infectious Disease convened by the Fogarty International Center. Of these, the National Institute of Allergy and Infectious Diseases (NIAID) supports the majority of the basic research and training in infectious disease, aimed at diagnosis, drug development, clinical trials, and ultimately vaccines. At NIH, behavioral research concerning infectious diseases primarily has been focused to date on HIV/AIDS acquisition and transmission.  A major gap in the research approach to EID is the role of behavioral interventions in prevention. Because a key component of the NINR mission is "to prevent or delay the onset of disease," that Institutes role in EID activities is not only a complement to NIHs other work, but an essential home for the focus on prevention through behavioral interventions.  Prevention, Control, Surveillance and Training Initiatives Educating children and adults about healthy behaviors, such as handwashing, is a priority for CDC along with its surveillance and immunization programs. CDC has the lead in developing and tracking the Department of Health and Human Services Healthy People Objectives for immunization and infectious disease. More than 30 national objectives have been identified for achievement by 2010, with the elimination of disparities among racial, ethnic and income groups being a major underlying goal.  NIAID is responsible for training as well as research in EID. It participated with CDC and the American Society for Microbiology in a March 1998 workshop that yielded six training recommendations, which include promoting international links and working with academia to develop curriculum and offer continuing professional education.8 The American Academy of Nursing (AAN) began an EID initiative in 1995. Its review of the recommendations for surveillance, prevention/control, applied research, and infrastructure development made by three organizations (CDC; the Institute of Medicine; and the Committee on International Science, Engineering, and Technology of the Presidents National Science and Technology Council) led to tailored recommendations for nursing. Participants at the 1995 AAN meeting stressed that nurses can play an active role in promoting science and health literacy among American youth.9 How Can Nursing Research Contribute? The June 3-4, 1999 Meeting While research initiatives such as those described above are making important contributions, significant gaps remain to be filled. Many lie in the area of applied behavioral research, especially within settings other than acute care, including homes and community institutions (schools, recreation sites, prisons, daycare centers, and so on). Not enough is known about what interventions work in non-acute care settings, nor about why interventions shown to be efficacious in controlling infection often prove ineffective when applied under less controlled conditions. One reason may be that classical behavioral research has not adequately taken into account contextual factors such as organizational climate.10 As these issues fall within the broad domain of nursing practice, the NINR has committed to developing a research agenda to contribute to control of emerging infections. To that end, the NINR invited an interdisciplinary team of 12 experts on infectious disease control to meet in Rockville, Maryland on June 3-4, 1999 to advise on the research agenda. The work group members included academics, researchers, agency administrators, and community public health workers. Their disciplines included microbiology, medicine, public health, and food safety, as well as nursing. (The members are listed at the end of this report.)  NINR Director Dr. Patricia Grady characterized emerging infections as "like the mythical Medusa" and noted that NIH is again looking at basic principles, including behavior, and adopting a systemic and global approach. One important research direction for NINR, she said, is to facilitate research so that nurseswho practice in all health care settings as well as homes and other community sitescan implement the following practices, among others: behavioral interventions to promote good hygiene; appropriate use of antimicrobials; vaccine guidelines; safe food handling and responsible travel precautions.  Methodology and Major Conclusions The two-day discussion was wide-ranging and productive, facilitated by a creative group process. The stage was set by overview presentations on initiatives from the NIAID, CDC and nursing organizations as well research within the community; on antibiotic resistance; and on key issues in behavior change. The group then engaged in an exercise in which they responded to the question, "What contributions can nursing research make to solving the problem of emerging infections?" This generated about 150 ideas that were compiled into three categories: anti-microbial resistance; clinical/health care settings and occupational health issues; and community and home.  In day two of the meeting, members formed two sub-groups in which they identified themes and gaps in each category and fleshed out and connected the ideas from the previous day. The group then combined these priorities into categories, representing their recommendations to the NINR for critical areas of research.  In short, they concluded that nursing research should be aimed at 1) characterizing risks, 2) understanding relevant beliefs and practices, 3) testing efficacious interventions in new settings, and 4) enhancing the effectiveness of interventions with demonstrated efficacy. In each context, work group members stressed the importance of looking at diverse settings and populations and testing a range of interventions.  Themes of the Discussion As the organizers had hoped, the diversity of the group led naturally to a broad approach to the subject matter. The members examined the settings and populations for targeted infection control efforts, the key EID "actors," and the possible types of interventions.  Although hospitals remain a major site of infection and infection control activities, much of health care and prevention activities occur not in the hospital but in nursing homes, ambulatory centers and private homes. Moreover, many individuals with chronic conditions participate in community life (e.g., special-needs children in public schools), where the potential for transmission of infections must be addressed.  The work group took these varied settings into consideration, recognizing as well that the battle against emerging infections is moving not just beyond the hospital but beyond typical health care settings. Surveillance and control efforts are focusing on public places such as swimming pools and agricultural worksites as well as on individual homes, particularly around issues of food and water safety. Ultimately, even as the scope is widening, it is also narrowing to focus on individuals and on their participation preventing infections. Members agreed that a broad educational effort to change behaviorfor example, to improve handwashing practicesmust target the young and be expected to take a generation to bring about the desired changes at the societal level.  The work group recommended including those with expertise beyond traditional health care such as architects and urban planners on interdisciplinary teams to reduce infections. They recognized that technologic innovations are an important part of the solution, and also called for international alliances, since pathogens know no boundaries and important research is taking place in other parts of the world.  Three types of interventions were identified, representing three areas of innovation:  behavioral/educational (e.g., school-based educational programs to improve handwashing practices)  engineering and technological (e.g., strategic location of automated sinks)  organizational/contextual (e.g., nursing home policy to promote vancomycin-resistant enterococci [VRE] monitoring and surveillance)  In addition, participants discussed the need to consider such factors as age, socioeconomic status (SES), culture, and race/ethnicity as well as beliefs and customs in designing and evaluating interventions. (See Table 1)    Table 1. Examples of population groups for study of interventions to reduce/prevent EID Age groups (e.g., infants, school-age children, adolescents, childbearing-age women, seniors)  SES groups (especially people with low incomes)  Racial and ethnic groups; language groups; recent immigrants  Rural/urban residents  Health care workers with special characteristics (e.g., pregnant, immune-compromised)  Other groups of workers (e.g., meat packers, migrant workers)  The work groups recommended priorities for an NINR research agenda on EID follow, with a few examples in each category.    Recommendations for Nursing Research 1. Characterize infectious disease risks  in various settings (home, school, outpatient, etc.)  in various populations (across life span, different ethnic/cultural/religious groups, etc.)  Examples of research ideas in this category:  Describe the relationship between host and social factors (e.g., culture, SES, religious practices, age, skin integrity, nutrition, genetics) and risk of infection.  Examine the relationship between foreign bodies such as bladder catheterizations and gastrostomy tubes, especially in nursing home patients, and acquisition of resident bacteria.  Describe the risk that care providers of persons positive for resistant organisms will acquire infections or become colonized with resistant strains while working in home or community settings. Evaluate transient vs. resident changes in flora.  Quantitate risks of infectious disease transmission within various settings (child care, schools, long-term care, homes).  Examine the relationship between SES (and other social, cultural or behavioral factors) and the prevalence of multidrug-resistant organisms or other emerging pathogens in populations.  2. Describe beliefs and practices related to infection prevention and control  in various settings (home, school, outpatient, etc.)  in various populations (across life span, different ethnic/cultural/religious groups.  Examples of research ideas in this category:  Describe the health beliefs, cultural practices, traditional folk medical practices of immigrant populations related to the detection, treatment, and transmission of infectious disease across the life span.  Evaluate the views of childcare workers and children in daycare about hygiene and handwashing.  Assess the impact of cultural/ethnic/rural-urban beliefs and practices on antibiotic use and infectious disease in relation to transmission, immunization, etc.  3. Transfer and test in home and community settings those interventions with demonstrated efficacy in the acute care setting (e.g., hand hygiene, use of vaccines, antibiotic use and prescribing patterns, use of disinfection and cleaning). Examples of research ideas in this category:  Evaluate the antibiotic prescribing practices of healthcare professionals and interventions that result in more appropriate practice.  Assess the nature of handwashing in home and childcare settings how and why people wash their handsand the relationship between hygienic practices and reductions in the risk of infections caused by pathogens that are transient on the hands.  Assess and characterize the barriers to effective implementation of standard infection control practices at the organizational (e.g., administrative) level in the hospital and non-hospital health care setting.  4. Promote the effectiveness of prevention and control practices (e.g., improving hand hygiene and use of barrier precautions) by testing different types of innovations (behavioral/educational, engineering/technological, and organizational/contextual innovations). Examples of research ideas in this category:  Develop and test the effects of technologic innovations (e.g., architectural and design modifications, physical or chemical barriers) on transmission of infections in various settings home, preschool, school, hospital, clinic.  Test different models of behavior change for effectiveness in lowering risks for emerging infectious diseases.  Other Recommendations Create partnerships that encourage innovations or applications of engineering and technological advances to reduce transmission of infectious agents.  Collaborate with other agencies (e.g., CDC, NIAID, NIMH) to identify and test promising infection prevention and control strategies.  Collaborate with other professional groups (e.g. urban planners, architects, media, agriculture specialists) to identify and test promising infection prevention and control strategies.  Develop research training opportunities to improve the quality and clinical outcomes of nursing research in EID.  Workgroup Members Elaine Larson, Ph.D., R.N., Chair  Professor, Pharmaceutical and Therapeutic Research  Columbia University School of Nursing  George W. Counts, M.D.  Assoc. Director for Clinical Research, DMID  National Institute of Allergy and Infectious Diseases  Robyn Gershon, Dr.P.H.  Assoc. Scientist, School of Public Health  Johns Hopkins University  William R. Jarvis, M.D.  Chief, Investigation and Prevention Branch, Hospital Infections Program  Centers for Disease Control and Prevention  (unable to attend)  Felissa R. Lashley, Ph.D., R.N.  Dean and Professor, School of Nursing  Southern Illinois University Edwardsville  Carol OBoyle, Ph.D., R.N.  Epidemiology Supervisor/Infection Control,  Disease Prevention and Control  Minnesota Department of Health  Curtis L. Patton, Ph.D.  Dept. of Epidemiology and Public Health  Yale University School of Medicine  Elizabeth Scott, Ph.D.  Consultant in Food and Environmental Hygiene  Newton, MA  Mary Lou deLeon Siantz, Ph.D., R.N.  Professor, Dept. of Family and Child Nursing, School of Nursing  University of Washington  Gerald V. Stokes, Ph.D.  Assoc. Professor and Acting Chairman, Dept. of Microbiology and Immunology  George Washington University  Joan G. Turner, D.S.N., R.N.  Professor, School of Nursing, University of Alabama at Birmingham  Robert A. Weinstein, M.D.  Chairman, Division of Infectious Diseases  Cook County Hospital  Professor of Medicine, Rush Medical College  For more information about NINR extramural research: research.htm 1. Department of Health and Human Services. Overview, Immunization and infectious diseases. Healthy People 2010 Objectives, 1999 draft for public comment. 2. Weinstein RA. Nosocomial infection update. Emerging Infectious Diseases 1998; 4: 416. 3. Healthy People 2010, ibid. 4. National Institute of Allergy and Infectious Diseases. Emerging infectious diseases research: meeting the challenge. 1997: 3. 5. Weinstein RA. Comment at June 3 workshop on NINR research agenda on emerging infectious diseases. See also Gold HS, Moellering, Jr. RC. Antimicrobial-drug resistance. New England Journal of Medicine 1996; 4: 1445-1451.  6. Morbidity and Mortality Weekly Report 1999; 48: 621. 7. Koplan J. Preface, Preventing emerging infectious diseases: a strategy for the 21st century. Centers for Disease Control and Prevention 1998: v. 8. Western K. ASM/CDC/NIH. Training in emerging and re-emerging infectious diseases. Emerging Infectious Diseases 1998; 4: 504-505. 9. Cohen FL, Larson EL. Emerging infectious diseases: nursing responses. Nursing Outlook 1996;44:164-8. 10. Kretzer EK, Larson EL. Behavioral interventions to improve infection control practices. American Journal of Infection Control 1998; 26: 245-253. 11. Centers for Disease Control. National Vital Statistics Report, Vol 47, No 9, November 10, 1998. Community Health Administration http://www.edcp.org/guidelines/vre96.html Introduction Background Goals of VRE Control in the LTCF Prevention and Control Measures Avoidance of Unnecessary Restrictions Tracking Notification of Providers Control of VRE Outbreak Situations Identification of Vancomycin-Resistant Staphylococci I. Introduction Vancomycin-resistant enterococci (VRE) have emerged in the past few years as epidemiologically important pathogens. VRE pose a unique public health threat because: A. Treatment of infection is quite challenging, since VRE are often resistant to multiple antibiotics, B. The potential exists for VRE to transfer genetic vancomycin resistance to other gram-positive organisms, including Staphylococcus aureus. This transfer has not yet occurred clinically. All health care institutions must become aware of the threat and involved in the control of these pathogens. Long term care facilities (LTCFs) may be especially challenged by VRE because of their at-risk patient population and frequent patient transfers to and from acute care institutions. II. Background Enterococci are gram-positive bacteria which are found normally in the gastrointestinal and female genital tracts. They may be identified on laboratory reports by several different names: Enterococcus faecium, Enterococcus faecalis, or Enterococcus species. Enterococci can also be found without causing infection along catheter sites and in the urine. Most enterococcal infections occur when enterococci are introduced into normally-sterile body sites (e.g., blood or urine). Clinical infections may include: endocarditis, urinary tract infections, intra-abdominal or pelvic infections, vascular line sepsis, and wound infections. Many enterococcal infections are mixed infections in which the role of enterococci is uncertain. All enterococci have intrinsic low-level resistance to some antibiotics. In recent years, however, some strains of enterococci have acquired high-level resistance to multiple antibiotics including aminoglycosides, ampicillin, and vancomycin. Virtually all VRE are E. faecium. Vancomycin resistance is of special concern because it makes treatment difficult, and because of the potential for this plasmid-mediated vancomycin resistance trait to be transferred to other microorganisms (although this has occurred in one experimental laboratory study to date). If methicillin-resistant S. aureus (MRSA) were to acquire vancomycin resistance, this pathogen would become virtually untreatable with current antibiotics. A dramatic increase in the incidence of VRE has been seen in the past few years. Although most outbreaks of VRE have occurred in acute care settings (especially intensive care units), all health care institutions have the potential to be affected. Risk factors for acquiring VRE infection or colonization include: severe underlying illness or immunosuppression, indwelling urinary or central venous catheters, recent abdominal or cardiothoracic surgery, prolonged hospital stays, stay on an ICU, oncology, or transplant ward, treatment with vancomycin, cephalosporins, metronidazole or clindamycin, or multiple antimicrobial agents and the number of days treated. Most enterococcal infections probably arise from bacteria in the patients own gastrointestinal tract. People who are colonized with the bacteria in their gastrointestinal tract may be colonized for long periods of time. Nosocomial spread has been documented to take place as well. Direct contact (person-to-person) and indirect contact (via equipment or hands of personnel) can both transmit the organism. Because of the serious nature of these infections, it is imperative to take steps to prevent such transmission. III. Goals of VRE Control in the LTCF The goals of VRE control in the LTCF should include: A. Preventing the transmission of VRE: to residents within the facility, to staff and visitors of the facility, and to those outside the facility when residents are transferred; B. Allowing for admission or readmission of patients with VRE; and C. Preventing the potential transfer of vancomycin resistance to other gram- positive microorganisms (including S. aureus and S. epidermidis) within the facility and the community. IV. Prevention and Control Measures A. Staff Education All staff working in a LTCF should receive education and training regarding the importance of VRE control. Education should be provided regularly, at least annually, and may be incorporated into a larger infection control training program. In addition, refresher training in infection control practices should be provided in response to any increase in VRE frequency within the facility. B. Prescriber Education The overuse of vancomycin has been implicated in promoting an increase in VRE. Education of antibiotic prescribers is also important in VRE control. LTCFs can distribute information on vancomycin use to their prescribers. The Centers for Disease Control and Prevention (CDC) has provided recommendations for the prudent use of vancomycin; these are included in a sample provider handout (Appendix A). Especially note that vancomycin use should be discouraged for: treatment in response to a single blood culture positive for coagulase-negative staphylococcus, if other blood cultures drawn in the same time frame are negative (#3), continued empiric use for presumed infections in patients whose cultures are negative for beta-lactam-resistant gram-positive organisms (#4), and primary treatment of antibiotic-associated colitis (C. difficile and others) (#8). C. Identification of Patients with VRE 1. Case Definition - A VRE case is defined as a resident who has been identified by culture to be currently infected or colonized with VRE. A notation should be made in the residents record (e.g., problem list and care plan) when he/she is identified as a VRE case. 2. Culturing - Culturing for VRE should be performed according to clinical criteria established at the LTCF. Routine screening of all residents, staff personnel, and environmental surfaces is not recommended. When culturing is performed, the LTCF should ensure that the laboratory: a. tests all enterococci-positive cultures for vancomycin resistance, b. is capable of detecting both high and moderate levels of vancomycin resistance, and c. reports VRE findings to the LTCF expeditiously D. Infection Control Practices Consistent application of sound infection control practices will reduce the spread of many nosocomial pathogens, including VRE. Such practices do not depend on the identification of VRE cases, and should be applied in all patient care situations. Specific practices which should be especially followed when caring for VRE cases include: Hand Washing, Gloves, and Gowns Antiseptic soap is recommended for hand washing. Staff and visitors should wash hands after any contact with a VRE case prior to leaving the residents room. A resident identified as a VRE case should wash his/her hands after any personal hygiene activities (e.g., toileting) and prior to leaving his/her room for group activities. A resident who cannot wash his/her own hands should be assisted with hand washing in these instances. Staff should wear gloves when providing care which involves any personal contact (e.g., changing clothes, bathing). In the course of resident care, gloves should be changed before further contact with clean surfaces, the resident, or staff if they have become soiled with potentially infectious material (e.g., stool, urine). After such care, staff should remove gloves and wash hands. Care should be taken to avoid touching environmental surfaces or other residents or staff after caring for a VRE case and prior to washing hands. Gowns should be worn if the providers clothing is likely to have substantial contact with a VRE case in the course of care. Gowns should be removed Environmental Surface Precautions Rooms of VRE cases should be cleaned daily; frequently touched surfaces (e.g., bed rails, bedside tables, doorknobs) should be cleaned with an EPA-approved hospital grade disinfectant-detergent, in accordance with the manufacturers instructions. It should be noted that, although VRE is difficult to treat in the individual, it is not more difficult to eradicate from environmental surfaces than other enterococci or similar bacteria. Patient-care equipment with which a VRE case has contact should be cleaned and disinfected prior to use on another resident. Upon discharge or transfer, the room of a VRE case should undergo "terminal cleaning" with an EPA-approved hospital grade disinfectant-detergent. Room Placement A VRE case should receive special consideration for room placement within the LTCF. The order of preference for room placement is: A private room; A room with other resident(s) known to be VRE cases (i.e., cohorting); or A room with other resident(s) who are not at increased risk for infection (e.g., residents without vascular lines, catheters, stomas, decubiti, or other wounds), and who do not have MRSA infection or colonization. A resident identified as a VRE case who is incontinent of either urine or feces (regardless of the site of documented infection or colonization) or who is unreliable in personal hygiene should be placed in a private room or cohorted in a room with another VRE case. A VRE case should never be placed in the same room as a resident with current MRSA infection or colonization Termination of Special Infection Control Practices A VRE case should be considered to carry the pathogen indefinitely, unless: three consecutive cultures, taken after antibiotic treatment has ceased and at least one week apart, from the original culture-positive site(s) are negative for VRE, and three consecutive cultures, taken after antibiotic treatment has ceased and at least one week apart, from stool or rectal swabs are negative for VRE. Once these negative cultures are documented, the individual can be considered VRE-free and special infection control practices may be terminated. V. Avoidance of Unnecessary Restrictions A. Activities within the LTCF A VRE case should not be excluded from therapeutic or group activities as long as reasonable personal hygiene is maintained. Care should be taken to prevent stool, urine, and other body fluids from contacting environmental surfaces outside of the residents room. B. Admission and Transfer of VRE Cases A VRE case may be admitted to or retained in a LTCF. Also, the presence of VRE infection or colonization should not in itself preclude transfer of patients between health care facilities. Transferring facilities should notify receiving facilities as far in advance as possible and again upon transfer whenever a VRE case is transferred . VI. Tracking All cases of VRE should be documented in a line-listing which is reviewed by professionals responsible for infection control at the LTCF. An example of a line-list format is included in Appendix B VII. Notification of Providers A residents primary care providers should be notified when the resident is newly identified as a VRE case. All primary care providers who admit residents to the LTCF should be notified whenever there is concern for increased transmission of VRE within the facility. VIII. Control of VRE Outbreak Situations When three or more VRE cases (not including newly admitted residents who have VRE or residents being readmitted after a hospitalization who have VRE) are identified in a six month period, the LTCF should report this finding to the Local Health Department. Consultation should occur whenever there is evidence of an increase in VRE rates or transmission between residents. IX. Identification of Vancomycin-Resistant Staphylococci If the LTCF becomes clinically suspicious or receives laboratory notification of a case of vancomycin-resistant Staphylococcus aureus (VRSA) or vancomycin-resistant Staphylococcus epidermidis (VRSE), the LTCF should immediately contact the Local Health Department for infection control guidance. The Maryland Department of Health and Mental Hygiene (DHMH), Division of Outbreak Investigation, (410) 767-6677, should also be notified if vancomycin resistance is suspected in these pathogens. The LTCF should have the laboratory contact the DHMH Division of Outbreak Investigation for guidance on where to submit the isolate for confirmatory testing Acknowledgment: These recommendations were reviewed by the individuals listed below. We appreciate their comments. John G. Bartlett, M.D., Johns Hopkins Hospital J. Mehsen Joseph, Ph.D., Maryland Department of Health and Mental Hygiene J. Glenn Morris, Jr., M.D., M.P.H.&T.M., University of Maryland Medical Center Trish Perl, M.D., M.Sc., Johns Hopkins Hospital Louis B. Polish, M.D., D.T.M.&H., University of Maryland Medical Center Harold C. Standiford, M.D., Baltimore Veterans Administration Medical Center Dorothea Stern, M.D., Maryland Department of Health and Mental Hygiene Chapter 13. Impact of Barrier Precautions in Reducing the Transmission of Serious Nosocomial Infections Chapter 13. Impact of Barrier Precautions in Reducing the Transmission of Serious Nosocomial Infections Ebbing Lautenbach, M.D., M.P.H., MSCE University of Pennsylvania School of Medicine Background Many nosocomial infections are easily transferable from patient-to-patient, either via the hands of healthcare workers,1,2 or through the contamination of inanimate objects, including clothing and equipment.3,4 For some infections, the threat to other patients is considered serious enough that many institutions employ special barrier precautions, such as the use of gloves, gowns and disposable equipment for all patient contact, in caring for patients colonized or infected with these pathogens. Vancomycin-resistant enterococci (VRE)5 and Clostridium difficile6 represent 2 typical examples of nosocomial pathogens that may trigger such precautions. Although adherence to barrier precautions to prevent the spread of particularly concerning nosocomial pathogens has obvious face validity, the utility of specific interventions and the optimal forms they should take remain unclear. This uncertainty may in part reflect the impact of particular aspects of the epidemiology of the targeted nosocomial pathogens—i.e., the benefit of a given strategy may vary in different settings and with different organisms. Consequently, this chapter contrasts with the review of handwashing (Chapter 13), a practice for which the benefit was regarded as sufficiently established to warrant focusing on strategies for improving compliance. While compliance with barrier precautions is also an important topic and likely plays a significant role in the efficacy of such interventions, this chapter analyzes the literature evaluating the benefit of the barrier precautions themselves. Pactice Description Barrier precautions include any activity designed to prevent the spread of nosocomial pathogens from patient to patient. This chapter reviews the following 3 practices: Use of gowns and gloves for all contact with patients colonized or infected with VRE and/or C. difficile: Healthcare workers typically don gloves and gowns when entering the room of an infected or colonized patient, and remove them upon exiting (followed immediately by handwashing) to reduce the likelihood of clothing or equipment contamination that could transmit pathogens to other patients. Use of dedicated or disposable examining equipment for patients colonized or infected with VRE and/or C. difficile: Hospital equipment (i.e., blood pressure cuffs, thermometers) remains in a patients room and is not carried from room to room. Patient and/or staff cohorting for patients colonized or infected with VRE and/or C. difficile: Patients colonized or infected with similar pathogens are admitted to specific floors of the hospital where designated healthcare workers care only for patients colonized or infected with these pathogens. Prevalence and Severity of the Target Safety Problem Nosocomial infections, including C. difficile-associated diarrhea and VRE, significantly increase the morbidity and mortality of hospitalized patients.5,6 Both infections are also associated with increased hospital costs. Recent evidence also suggests there may be a relationship between C. difficile and VRE, with C. difficile infection identified as a risk factor for VRE infection.7 The increased incidence of both VRE and C. difficile can be attributed to spread from patient to patient.5,6 Failure to recognize these dissemination patterns may result in an inability to contain outbreaks when they occur in the hospital. C. difficile has been identified as the major, if not only, important cause of infectious diarrhea that develops in patients after hospitalization, occurring in up to 30% of adult hospitalized patients who developed diarrhea.5 One study found an acquisition rate of 13% for patients hospitalized 1-2 weeks,8 which increased to 50% for patients hospitalized >4 weeks. In addition, the incidence of C. difficile infection has increased in recent years, with one study reporting a 5-fold increase in clinical infection between 1993 and 1996.9 C. difficile infection increases lengths of stay, often to as long as 18-30 days10,11 and, when fulminant, can lead to exploratory and therapeutic surgical procedures. Mortality attributable to C. difficile, while reported, occurs in fewer than 5% of patients.13 The costs associated with C. difficile diarrhea, while not well described, may be as high as $10,000 per patient.14VRE, first described in 1988, currently accounts for greater than 25% of all nosocomial enterococci.6 Early national data suggested that infections with VRE were associated with mortality rates of over 36%, more than double that of patients with vancomycin-susceptible (VSE) infections.15 While later studies called some of these results into question,16,17 the most recent studies have again suggested that vancomycin-resistance carries an independent effect on mortality.18 VRE infections are also associated with significantly higher hospital costs than those due to VSE.18 Although C. difficile and VRE are among the most common nosocomial pathogens that have significant effects on morbidity, mortality, and cost, there are a number of other nosocomial pathogens which could also be studied. These include pathogens such as methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum beta-lactamase (ESBL) producing Enterobacteriaceae, Acinetobacter species, and Pseudomonas aeruginosa. While these are all important nosocomial pathogens, C. difficile and VRE were chosen as examples because they are extremely common, and they represent both antibiotic-susceptible (C. difficile) and antibiotic-resistant (VRE) pathogens. Additionally, (unlike MRSA and P. aeruginosa) the epidemiology of both pathogens is complex, representing both person-to-person spread and association with prior antibiotic use, allowing for a more comprehensive discussion of the relative merits of both antimicrobial use interventions and barrier precaution interventions (see Chapter 15 for more discussion regarding other antimicrobial intervention practices) and their general application to other pathogens. Opportunities for Impact As noted above, both VRE and C. difficile affect a large proportion of hospitalized patients. Improvements in barrier precaution interventions against these pathogens would have a tremendous impact. There are few data regarding the percentage of hospitals that employ any one of a number of barrier precautions (e.g., gowns, gloves, disposable thermometers).19 In addition, while standard practice is to apply barrier precautions for patients with nosocomial pathogens with demonstrated horizontal spread, compliance with precautions is frequently poor,20 often below 50%.21 Purported reasons for this lack of compliance include lack of resources and busy staff workload.20 Regardless, these results suggest that the opportunity for improvement in these practices is great. Study Designs A structured search of the PubMed database (including MEDLINE) and review of the bibliographies of relevant articles identified 19 studies that have examined the implementation of barrier precaution practices designed to impact the incidence of VRE and/or C. difficile infection (Table 13.1, 13.2, 13.3). All studies found on literature search were included in this review except for those reporting very small outbreaks (defined as fewer than 10 cases of C. difficile or VRE). Sixteen of the reviewed studies were before-after observational cohort studies (Level 3), in which baseline data regarding incidence of VRE or C. difficile were obtained during an observational period and compared to a second period after implementation of an intervention. Crude comparability data on the before and after groups (e.g., total admissions, patient census) were provided in 2 reports22,23 while only one study statistically compared the before and after groups to assess comparability.24 Three reports25-27 detailed unblinded comparative studies (Level 2) in which patients on different wards were assigned different interventions. Each of these studies assessed the comparability of the study groups on the basis of underlying demographic variables. Study Outcomes All of the studies reviewed reported changes in the incidence or prevalence of either VRE or C. difficile as a result of barrier precaution interventions (Level 1). For studies investigating C. difficile, all outcomes were reported in terms of clinical infections. For studies investigating VRE, outcomes were reported as VRE colonization and/or infection rates. Evidence for Effectiveness of the Practice As both VRE and C. difficile have clearly been shown to be transferable from patient-to-patient, interventions designed to improve barrier precautions yield significant reductions in the incidence of infection with these two pathogens. All studies that examined the effect of enhanced barrier precautions on C. difficile infection demonstrated benefit, suggesting that barrier precaution interventions are effective in controlling its emergence. Most studies employed a multifaceted approach including several different barrier precaution components. For example, one study combined use of vinyl gloves and ongoing educational interventions,26 another included cohorting, culture screening, and daily room disinfection,28 while another combined reinforcement of enteric precautions, replacement of electronic thermometers, and institution of closed paper towel dispensers.29 Given the varied components of barrier precaution interventions instituted in different studies, it is difficult to determine the specific effect of any individual component. The evidence of effectiveness of barrier precautions for VRE is somewhat less clear-cut. All but 427,30-32 of the studies examining the effect of barrier precautions on VRE demonstrated a benefit, but study design differences and particular epidemiologic trends may account for the inconsistent findings. One of the 4 studies that noted no significant effect compared glove use to glove and gown use.27 The second30 noted that the emergence of VRE at the study institution was due to multiple genetically-unrelated strains, suggesting that person-to-person spread was less important at that site. It is thus not surprising that barrier precautions would have less of an effect. In the third study,32 routine rectal swab surveillance and contact precautions were instituted in response to a clinical outbreak of VRE and surveillance was continued for only 6 months. Since surveillance was not conducted prior to institution of precautions, it is impossible to say what the colonization prevalence had been prior to the intervention. Furthermore, as the authors point out, it may be that the outbreak would have been much worse had the precautions not been put in place. Finally, no determination of genetic relatedness (and hence spread) was made in this study. In the fourth study,31 while there was a reduction in the isolation of VRE, there was not complete eradication. According to the authors, the most likely reason for this less-than-optimal response was poor compliance with contact precaution guidelines.Thus, it appears that enhanced barrier precautions are generally effective in reducing the incidence of VRE but that various aspects of both the epidemiology of the VRE outbreak and the implementation of guidelines may temper the effectiveness of interventions. Similar to the studies investigating response of C. difficile to barrier precautions, most studies of VRE employed several components of barrier precautions as part of a multifaceted approach (Table 13.1). It is thus difficult to determine the specific effect of any individual component. Potential for Harm None of the reviewed studies reported any assessment of possible harmas a result of the barrier precaution interventions. In fact, the implementation of barrier precautions is unlikely to result in harm to the patient. One potential concern is that time necessary to comply with the interventions (e.g., gowning, gloving), might make healthcare workers less likely to complete tasks necessary to provide acceptable patient care. Indeed, it has recently been noted that healthcare workers were half as likely to enter the rooms of patients on contact isolation.33 Furthermore, while contact precautions appeared to have little effect on patient examination by resident physicians, attending physicians were 50% less likely to examine a patient on contact precautions compared to a patient not on precautions.34 Future studies should address these concerns by documenting the time required to adhere to barrier precautions, and determining the potential impact of precautions on patient care. Another potentially harmful consequence of barrier precaution interventions is the psychological effect that contact precautions may have on the isolated patient. While research has examined the effects of sensory deprivation and social isolation, a recent review of the litera Read More